Examination

Fact

Explanation

Petechiae, Ecchymotic patches [4] [5] [6] [7] [8]

Petechiae are small (<3 mm) red or purple spot on the skin, caused by a minor hemorrhage and they do not blanch on pressure and Ecchymotic patches are larger than petechiae and these manifestations are due to low platelet count. [4] [5] [6] [7] [8]

Gum bleeding [1] [2] [4] [5] [6] [7] [8]

Low platelet count may result in bleeding from gums and can be clinically seen [1] [2] [4] [5] [6] [7] [8]

Disseminated intravascular coagulation (DIC) is systemic activation of clotting mechanisms and contributing to multiple organ dysfunction syndrome (MODS) by forming microvascular thrombi in various organs., In DIC patient will be very ill and consumption of platelets may cause a thrombocytopenia. [8]

Gestational thrombocytopenia [9]

Hemodilution and accelerated platelet clearance causes gestational thrombocytopenia and this doesn't affect the baby and recovers spontaneous after delivery.[9]

Systemic Lupus Erythematosus in pregnancy [10] [11]

Systemic lupus erythematosus (SLE) is an autoimmune disorder and can excerbate during pregnancy with arthritis, rashes, and fatigue. Rashes occur in SLE can mimic ITP. [10] [11]

An inherited disorder with dysfunction or deficiency of the protein termed von Willebrand factor (vWF) and type II B is a qualitative deficiency of the factor and associated with low platelet count [13]

Acute fatty liver of pregnancy [1]

There's accumulation of fatty acids in hepatocytes due to mitochondrial oxidation defetc. Clinically they have non specific symptoms such as malaise, nausea and vomiting, right upper-quadrant and epigastric pain. [1]

Antiphospholipid Syndrome [14] [15]

Recurrent venous or arterial thrombosis and/or fetal loss are the principal manifestations in antiphospholipid syndrome and sometimes can mimic ITP because of thrombocytopenia. [14] [15]

Investigations - for Diagnosis

Platelet counts are low as well as hemoglobin could be low due to bleeding. White cell count is also important to exclude any infective cause [1] [2] [3] [4] [5] [6]

Peripheral smear [1] [2] [3] [4] [5] [6]

Platelets are normal
to large in size. Red and white blood cells are usually normal in ITP [1] [2] [3] [4] [5] [6]

Antiplatelet antibodies [1] [2] [3] [4] [5] [6]

This test is not commonly done but these can be detected in the serum of women with ITP. [1] [2] [3] [4] [5] [6]

Bone marrow aspiration [1] [2] [3] [4] [5] [6]

This may demonstrate increased numbers of megakaryocytes. Usually this is not necessary unless patient is having lymph node enlargement or organomeagly. But this is usually done before splenectomy. [1] [2] [3] [4] [5] [6]

SHULMAN M. A., THOMPSON B. R.. I. Not fit for a haircut ... how should we assess fitness and stratify risk for surgery?. British Journal of Anaesthesia [online] December, 112(6):955-957 [viewed 27 August 2014] Available from: doi:10.1093/bja/aeu003

Management - General Measures

Fact

Explanation

Patient education [1] [2] [3] [4] [5] [6]

Patient should be educated regarding the nature, course and prognosis of the disease. Also should be reassured that there will be no harm for the baby due to the disease, and should be advised on the importance of follow up and available treatment options. Patient should be educated on warning signs such as headache, paralysis of a limb, aphasia (Features of intracranial hemorrhage)to seek immediate medical attention. [1] [2] [3] [4] [5] [6]

Follow up [1] [2] [3] [5] [6]

No treatment is necessary if platelet counts remain above 50,000/μL and the patient is asymptomatic. Therefore regular follow up of the patient is important with attending to obstetric care. [1] [2] [3] [5] [6]

Activity [1] [2] [3] [4] [5] [6]

When there is very low platelet count, any activity which can cause trauma is better avoided [1] [2] [3] [4] [5] [6]

Management - Specific Treatments

Fact

Explanation

Steroid therapy [4] [5] [6] [7] [10]

Prednisolone is used as the first line treatment. But treatment is not needed if platelet counts remain above 50,000/μL and the patient is asymptomatic. But even if the patient is having abnormal bleeding, or prior cesarean delivery which is invasive treatment will be carried out. [4] [5] [6] [7] [10]

Intravenous immune globulin (IVIG) [4] [5] [6] [7] [10]

IV immunoglobulin blocks the attachment of antiplatelet antibodies to platelets and gives a rapid response. especially in instances such as prior to surgery or bleeding. But this is very expensive. [4] [5] [6] [7] [10]

Anti-D immunoglobulin [4] [5] [6] [7] [10]

This is for Rh-positive women but still controversial when it comes to use. Anti-D immunoglobulin binds to maternal red blood cells and blocks the Fc receptor. Then there's phagocytosis of these anti D bound red blood cells in the reticulo-endothelial system in the spleen. [4] [5] [6] [7] [10]

Azathioprine [8] [10]

This is the only immunosuppressive drug used in pregnancy. Vinca alkaloids, androgens, and most immunosuppressive drugs are not recommended in pregnancy. Dapsone, and Danazol are not recommended in pregnancy. [8] [10]

Splenectomy [8] [10]

Antibody bound platelets are destructed in the spleen. Therefore aplenectomy will help to chieve remission and carried out in first and second trimesters. Prior to splenectomy, immunization against pneumococcus, meningococcus, and Haemophilus influenzae is done. [8] [10]

Management of the delivery [10]

Vaginal delivery is carried out unless a obstetric reason justifies the C-section. Platelet transfusions, IV Ig might be helpful in the management of delivery. [10]

Management of neonatal thrombocytopenia [1] [2] [3] [10]

cord blood platelet count determined at birth and again at 24 hours in these newborns born to mothers with ITP.
And then repeated daily for the next few days. Any neonates with severe thrombocytopenia (platelets < 30 × 109/l) is treated with IVIG regardless of presence or absence of bleeding. [1] [2] [3] [10]